Provider Demographics
NPI:1053347997
Name:BOURNE, EUGENE E (MD)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:E
Last Name:BOURNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6428 S BLACKHAWK WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-3149
Mailing Address - Country:US
Mailing Address - Phone:720-870-5109
Mailing Address - Fax:
Practice Address - Street 1:6428 S BLACKHAWK WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-3149
Practice Address - Country:US
Practice Address - Phone:720-870-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ119602085R0202X
CO201122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01201128Medicaid
AZ636558Medicaid
COC809549Medicare PIN
COC803975Medicare PIN
CO300028879Medicare PIN
CO01201128Medicaid
COD23714Medicare UPIN
AZ636558Medicaid
COC801369Medicare PIN
AZ69186Medicare ID - Type Unspecified